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Vol.
4 • January
2012 • ISSN:
2094-9537
Advancing
Nursing
Research
doi: http://dx.doi.org/10.7828/anrj.v4i1.198
Advancing Nursing Research
Perceptions of White Uniform
in the Nursing Profession
JEFFREY ALINO
LORMA B. APROSTA
RICCA MARIE I. LUGOD
AMY RUTH G. MONTILLA
JULIUS C. TABUAN JR.
CHRISLYN B.UBA
College of Nursing
Liceo de Cagayan University
Abstract - This study determined the perceptions of professional
nurses towards the color white as the standard color for hospital
uniforms. The specific objectives are the following: 1. To determine
the profile of the registered nurses according to: age, gender, length of
clinical experience, clinical area, position, hospital policy in terms of
hair, shoes, and color; 2. To determine their perceptions whether ProWhite or not and their reasons. Using a descriptive design, personal
interviews were conducted on 30 nurses- 10 each from Polymedic
General Hospital, Maria Reyna Hospital, and JR Borja Hospital.
Respondents are Generation Yers which according to studies prefer
uniforms with print to make them look approachable. Regarding
gender, majority of nurse-respondents are females consistent with the
observation that nursing is in itself a female-dominated course and
profession. A wide range of clinical practice in respondents could
be noted. Majority served from less than a month to five years and
assigned in the Medical Ward. Most are staff nurses and a few trainees
and one senior nurse. Based on Benner’s model, it could be said that
the staff nurses are competent. JR Borja strictly adheres with the policy
of wearing white uniforms compared to Polymedic General Hospital
and Maria Reyna Hospital. In PGH, nurses wear colored uniforms and
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only trainees wear the traditional white uniform without cap. In MRH,
station nurses wear white uniforms. In the ER, NICU, ICU, green or blue
scrub suits are worn and no cap. The hospitals differed in their policy
for hair. Hair should be kept tidy but not necessarily in a bun. Tying hair
is very common in PGH. In the other two, hair must be fixed in a bun.
Male nurses should sport a clean haircut. All hospitals mandate the
wearing of white shoes. Personal views of the white uniform as standard
attire in hospitals were associated with neatness or cleanliness. The
respondents claimed that a white uniform is significant to the nursing
profession for it represents virtues/attributes of effective nurses which
include cleanliness/purity, respect, professionalism, passion for work
and profession/commitment, trademark of profession, smartness,
beauty, elegance, patience, nobility, pride, honor, self-discipline and
honesty. In conclusion, white uniforms play a vital role in protecting
the image of nurses. These views were constructed from culturallyand socially-based definitions and images of nurses which led patients
to hold them at a highly-esteemed position for their professionalism
and compassion.
Keywords: white uniform, standard, Polymedic General Hospital,
Maria Reyna Hospital, JR Borja Hospital
INTRODUCTION
A uniform is a set of standard clothing worn by organization
members participating in their various activities. Modern uniforms
are worn by armed forces and paramilitary organizations such
as police, emergency services, security guards, in some workplaces
and schools and by inmates in prisons. Workers sometimes wear
uniforms or corporate clothing of one nature or another. Workers are
required to wear uniforms as well. The wearing of uniforms is the
organization’s effort of branding and developing a standard corporate
image but also has beneficial effects on the wearer. However the
term ‘uniform’ is misleading because employees are not always
fully uniform in appearance and may not always wear the attire
provided by the organization, yet still representing the organization
in their attire. Academic work on organizational dress by Rafaeli and
Pratt (1993) referred to uniformity (homogeneity) of dress as one
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dimension, and conspicuousness as a second. Employees all wearing
black, for example, may appear conspicuous and thus represent the
organization even though their attire is uniform only in the color of
their appearance not in its features. Pratt and Rafaeli, (1997) described
struggles between employees and management about organizational
dress as struggles about deeper meanings and identities that dress
represents. Pratt and Rafaeli (2001) described dress as one of the larger
set of symbols and artifacts in organizations which coalesce into a
communication grammar. In the nursing profession, nurses are guided
by the core values which include human dignity, integrity, autonomy,
altruism, and social justice.
Bacon, McKendrick, and McKendrick (2000), Kiger (1993) and
Rossiter and Yam (1998) explained the persistence of the stereotypical
images of nurses and the profession itself. More often, a nurse is
portrayed a battleaxe, a sex symbol or in a subordinate role and
handmaiden to the doctor. These persistent images discourage young
people into taking the nursing course.
For some time, nursing organizations have concerned themselves
the positive projection of nurses. Unfortunately the stereotypical
image still remains and these are the images that are usually retained
by prospective nursing students when they see themselves as nurses;
this factor is of great significance in this study. In 2000, Bacon and
McKendrick reported a change in how nurses are being perceived in
public. Now, nurses are regarded as well-educated and independent
thinkers and this perspective may reflect that vision that the nurse is
now a major player within a high-tech medical world.
In various industries, a strict dress code and design is imposed
especially the uniforms being worn which are not only appealing to
clients/consumers but also convey professionalism. In health care,
the nurse’s uniform makes the first impression on the clients and
believe that the ideal choice is functional, but outfit should also inspire
patient confidence. Nursing leaders in medical facilities, conscious
of how patients associate professionalism with appearance, ponder
implementing dress codes to require all-white nursing uniforms.
Critical care nurse specialist Lucia Wocial, Ph.D. and others (2010)
report that patients identify nurses by the color of nursing uniform
and associate all-white uniforms with caregiver competency and
professionalism. However, Wocial observes that patients also associate
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“smallprint uniform tops” with “caring, attentiveness, cooperation
(and) empathy” in their caregiver. The study indicates that nursing
uniforms do not have to be all white to convey positive attributes of
caregiving (Breeze, 2011).
By using a variety of methodologies with patients and their significant
others, researchers were able to determine if the nurse uniforms play
the essential role in the delivery of care or nurse professionalism.
Interviews conducted by Campbell et al. (2000) revealed important
factors in nurse uniforms. Families preferred nurses who can be easily
identified and for the uniform to encourage a relaxed atmosphere.
Families also wanted more casual uniforms that increase the nurse’s
approachability, like colored polo shirts which distinguishes staff by
role and rank with trousers, shorts, or navy skirts.
In 1991 and 1997, Mangum and colleagues examined the effect that
nurse uniforms have on the perceptions of image and professionalism.
The researchers made use of 10 professional traits in nurses according
to literature (empathic, cooperative, reliable, professional, caring,
approachable, efficient, attentive, competent, and confident) and
surveyed patients utilizing the Nurse Image Scale. Both studies
revealed that the patients’ scores in the NIS were not significantly
related to the color and style of the nurse’s uniform.
FRAMEWORK
The study was anchored on the person–environment fit theory.
The person–environment fit denotes that the characteristics of the
employees are compatible with the work environment, or between the
occupational needs of the employees and the organizational capability
in reinforcing these needs (Dawis & Lofquist 1984, Walsh & Holland,
1992). The theory states that when the employees perceive a fit between
the person and environment, they more likely show more favorable
occupational behaviors, like better job performance and job satisfaction,
and low intention to leave their vocation (Dawis & Lofquist 1984,
Walsh & Holland, 1992 as cited in Walsh, Craik, & Price, 1992). When
a misfit is perceived (i.e. incompatibility between their characteristics
and those of the environment/job), employees become frustrated and
dissatisfied with their job. To correct the incompatibility, employees
should adjust their characteristics to the environment or attempt to
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modify their environment. The ultimate solution to this burden is
leave the organization or occupation and search for a more compatible
environment or job (French & Kahn, 1962; Dawis & Lofquist, 1984).
The uniform worn by a nurse powerfully symbolizes professionalism
(Spragley & Francis, 2006). This is particularly true among adults who
perceive that a nurse’s professional is based partly on the color and
style of the uniform (Albert et al. 2008). In the pediatric ward, the more
traditional, all-white dress or pant suit is replaced by brightly colored
uniforms; however, it is not known whether or not the color and style
of uniform affects adult and pediatric perceptions of the nurse as a
professional.
Skorupski and Rea (2006) revealed that wearing a white uniform
conveys efficiency, professionalism, competence, reliability, and
confidence and uniforms with small printed tops conveyed traits of
approachability, empathy, cooperation, attentiveness, and caring. A
study of adult patients showed that nurses donning uniforms with
small-print were the preferred caregiver, and a nurse wearing a white
uniform can be easily identified. It is also significant to determine if the
uniform of the nurse is a meaningful indicator of being approachable
and other nurse professionalism traits to patients and visitors.
A common yet poorly delineated concept in organizational and
industrial psychology is job performance. It is defined as whether the
individual has performed his or her job well. Despite no clear and exact
definition has been given to the term, performance is a very significant
criterion in relation to organizational success and outcomes. A widely
acknowledged theory is from Campbell and colleagues (1990). These
workers described job performance to be a variable at the individual
level. That is, performance is anything a person or an employee does
on the job. This sets it apart from more encompassing constructs
like organizational or national performance which are higher level
variables.
Maslow (1943) introduced a theory that determines how individuals
are able to satisfy personal needs in the context of their respective
jobs. Basing on his observations being a humanistic psychologist, he
claimed that a general pattern of recognizing and satisfying needs
exists and that this same sequence is generally being followed. His
theory also suggested that a person’s needs are arranged hierarchically
and in order for a person to address the next level of needs, those
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below it must be substantially or completely satisfied. This concept
is known as prepotency. In other references, it is presented as a
pyramid with the survival need occupying the bottom while at its
peak is self-actualization. The first level is physiological (thirst, sex,
hunger), followed by safety (security, stability, protection), love and
belongingness (to escape loneliness, love and be loved, and gain a
sense of belonging), then esteem (self-respect, the respect of others),
and self-actualization (to fulfill one’s potentialities).
According to Herzberg’s original study, motivation factors produce
job satisfaction. Nelson and Quick said:
“Motivation factors lead to positive mental health and challenge
people to grow, contribute to the work environment, and invest
themselves in the organization, and they directly affect a person’s
motivational drive to do a good job. Job dissatisfaction occurs when
the hygiene factors are either not present or not sufficient. The hygiene
factors relate to the context of the job and may be considered support
factors. They do not directly affect a person’s motivation to work but
influence the extent of the person’s discontent. The hygiene factors
cannot stimulate psychological growth or human development. They
may be thought of as maintenance factors, because they contribute to
an individual’s basic needs” (2003, p. 160).
Clayton Alderfer of the Yale University in 1969, recognizing the value
of Maslow’s hierarchy of needs theory and evolutionary development,
developed the ERG Theory. Contained in the ERG Theory are human
needs classified into Existence, Relatedness, and Growth needs. Nelson
and Quick (2007) said, “Alderfer classified Maslow’s physiological
and physical safety needs in an existence need category; Maslow’s
interpersonal safety, love, and interpersonal esteem needs in a realness
need category; and Maslow’s self-actualization and self-esteem needs
in a growth need category” (p 156). Robbins (2003) as cited in Politis
(2006) believed that “In contrast to the hierarchy of needs theory, the
ERG theory demonstrates that (1) more than one need may be operative
at the same time, and (2) if the gratification of a higher-level need is
stifled, the desire to satisfy a lower-level need increases” (p 161). The
theory of Maslow maintained that it is only when a certain need level
is met that the individual progresses to the next need level. The ERG
theory implied that individuals increase their lower-order needs with
remoteness of the attainability of higher-order needs.
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Article IV, section 8 or Nursing practice of RA 9173 states:
“A person shall be deemed to be practicing nursing within the
meaning of this Act when he/she singly or in collaboration with
another, initiates and performs nursing services to individuals, families
and communities in any health care setting. It includes, but not limited
to, nursing care during conception, labor, delivery, infancy, childhood,
toddler, preschool, school age, adolescence, adulthood, and old age.
As independent practitioners, nurses are primarily responsible for the
promotion of health and prevention of illness. Members of the health
team, nurses shall collaborate with other health care providers for the
curative, preventive, and rehabilitative aspects of care, restoration of
health, alleviation of suffering, and when recovery is not possible,
towards a peaceful death. It shall be the duty of the nurse to:
(a) Provide nursing care through the utilization of the nursing
process. Nursing care includes, but not limited to, traditional and
innovative approaches, therapeutic use of self, executing health care
techniques and procedures, essential primary health care, comfort
measures, health teachings, and administration of written prescription
for treatment, therapies, oral topical and parenteral medications,
internal examination during labor in the absence of antenatal bleeding
and delivery. In case of suturing of perineal laceration, special training
shall be provided according to protocol established;
(b) Establish linkages with community resources and coordination
with the health team;
(c) Provide health education to individuals, families and
communities;
(d) Teach, guide and supervise students in nursing education
programs including the administration of nursing services in varied
settings such as hospitals and clinics; undertake consultation services;
engage in such activities that require the utilization of knowledge and
decision-making skills of a registered nurse; and
(e) Undertake nursing and health human resource development
training and research, which shall include, but not limited to, the
development of advance nursing practice;”
A hospital is an institution that provides medical services to the
sick, injured, and pregnant. With its support, nursing, and medical
personnel, the institution cares for both in- and outpatients. Caring
plays an essential part to ensure that human beings survive and
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develop their fullest potentials (Skott & Lundgren, 2006). In the health
profession, caring seems to be widely debated most especially among
nurses (Boykin & Schoenhofer, 2001). The brilliant work of Watson
(1985) said that caring is the moral ideal in the nursing profession. He
added that caring is closely tied to the preservation of human dignity
in curative health care systems and considered the gold standard in
which cure is measured. Watson (1979) defined caring as the process
which involves knowledge, action, and consequences and enumerated
ten “carative” factors which can be incorporated into practice in any
hospital setting.
To ensure that Filipino nurses adhere to the ideals required by the
profession, the Philippine Board of Nursing (PNA) together with the
Commission on Higher Education (CHED) on Nursing Education
in April 2001 created a committee on Core Competency Standards
Development. The principal objective of this initiative is develop
competency standards by which nursing practice will be grounded in
the Philippines which is stipulated in Article 3 Sec. 9 (c) of R.A. 9173
or the “Philippine Nursing Act of 2002” stating that PNA will examine
and enforce standards of quality nursing care. This enables the nurse to
uphold efficient, ethical, technical, moral, and professional standards
of nursing practice taking into consideration of nation’s health needs.
These standards will be the unifying framework in nursing education,
regulation and practice. In the context of nursing practice which
is this research’s area of concern, the standards protect the public
from incompetent nurses and a yardstick for ethical and professional
nursing practice. By conducting this research, a host of problems in the
nursing profession will be reduced.
The Philippine health care system is predominantly comprised of
nurses working 24 hours a day, 365 days in a year and patients come to
the hospitals seeking care. The purpose of this study is to evaluate the
perceptions of registered nurses on using the color white as the standard
color of uniforms in the hospital. The researchers find it important to
address this issue amid the many images of nurses portrayed by the
media. Unfortunately, advertising and media companies depict nurses
in an inaccurate and unflattering manner. In the 40s and 50s, nurses
are portrayed as “angels of mercy” - selfless professionals dedicated
to their chosen vocation and loyal to their nation. Then during the 60s,
when medical films and dramas began to emerge, nurses are shown
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as “doctors’ handmaidens,” “battleaxes,” and most popularly, “sex
kittens” – images that still exist today. As members of the Philippine
Nursing Association, registered nurses are duty bound to behave in a
manner which is in keeping with the role of the nurse and the PNA’s
standards.
Nurses from all around the world wear different uniforms; most
countries wear the traditional white uniform consisting of a cap and
dress. For males, a tunic with a V-neck is often used. Colors differ
according to grade, area of work, and hospital; however, the male
equivalent of charge nurse is bluish or dark greenish: often, this color
is often associated with authority.
OBJECTIVES OF THE STUDY
This study determined the perceptions of professional nurses
towards the color white as the standard color for hospital uniforms.
The specific objectives of this research are 1.) To determine the profile
of the registered nurses according to age, gender, length of clinical
experience, clinical area, position, hospital policy in terms of hair,
shoes, and color; and 2.) To determine their perceptions whether ProWhite or not and their reasons.
RESEARCH FLOW
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SIGNIFICANCE OF THE STUDY
This study will be beneficial to the following groups:
Nursing Service. The findings of the study would be a reference to
healthcare professionals to be guided on how to teach future nurses
to provide best care possible to their patients making them respectful
of their responsibilities toward society; thereby giving dignity to the
negative image of nurses.
Nursing Staff. The findings of this study will provide evidence on
how professional nurses perceive the significance of wearing white
uniforms in their hospital responsibilities.
Student nurses. The findings of this study would be a help among
nursing students to learn more about the comprehensive strategy of
the DOTS program as well as conduct counseling and observation of
patient’s regular intake of medicines.
Future researchers. This research will foster a sustained curiosity
and interest on how the wearing of white uniforms can affect the
competency and performance of professional nurses. Moreover, this
study will also help in updating and enhancing perceptions of the
beneficiaries.
SCOPE AND LIMITATIONS OF THE STUDY
This study was limited to how nurses perceive the white uniform
as standard attire for hospital nurses and their reasons and the
significance of the white uniform in the nursing profession. Data
gathering was for a period of two weeks. Respondents were limited to
30 professional nurses; ten in each of the following hospitals Polymedic
General Hospital, Maria Reyna Hospital, and JR Borja Hospital. Profile
of the respondents included age, gender, length of clinical experience,
clinical area, position, and hospital policy in terms of hair, shoes, and
color.
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MATERIALS AND METHODS
The design of the study was descriptive. According to Polit
and Beck (2004), the purpose of descriptive studies is to observe,
describe, and document aspects of a situation as it naturally occurs
and sometimes the starting point for hypothesis testing or theory
development. Thus, the design was appropriate for the study because
knowing the phenomenon during the span of treatment would lead to
the evaluation of their present condition. It is qualitative since it used
content analysis in analyzing significant data of the study.
Primary data were collected by employing a semi-structured
interview guide. The data gathering for this particular study proceeded
as follows. Prior to data collection, approval was obtained from the
Dean of the College of Nursing, Liceo de Cagayan University. After
which, a letter was written and submitted to the Hospital Administrator
of Polymedic General Hospital, Maria Reyna Hospital, and JR Borja
Hospital, seeking permission to interview ten professional nurses. The
letter stated the nature and purpose of the study and was approved by
the Research Adviser. After permission was granted, data gathering
commenced. The selected respondents were asked to sign an informed
consent to ensure their willingness to participate in the study. The
whole interview was transcribed.
Content analysis was done on collected data. Krippendorff (2004)
defined that in content analysis, content of text is explored in which
values, interests, and attitudes were revealed. During the analysis, the
researchers described text elements which could be words, sentences,
connotations, associations, and metaphors. Interpretation of these
elements then followed. These elements were counted then deductively
assigned to predefined categories (Weber, 1990).
RESULTS AND DISCUSSION
The respondents are mainly 30 years old and below which meant
that they belong to Generation Y. It was identified that younger
generation nurses would prefer uniforms with print to make them
look approachable. It is also deduced that older nurses more likely
want to retain tradition through wearing white uniforms (Skorupski
& Rea, 2006). Regarding gender, majority of nurse-respondents are
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females (N=22 or 73.33%) and only eight or 26.67%. This frequency
is consistent with the observation that nursing is in itself a femaledominated course and profession. There seemed to be a wide range
in the clinical practice of respondents (less than a month-25 years).
Twenty-six out of 30 (86.67%) served from less than a month to five
years; 10 percent (N=3), six to ten years; and 3.33 percent (N=1), 25
years. Nineteen (63.33%) are assigned in the Medical Ward; 20 percent
(N=6), OB Ward; 10 percent (N=3), DR; 3.33% each (N=1) in Neonatal
Intensive Care Unit and Pediatric wards. Most respondents are staff
nurses (N=27, 90%). Trainees composed 6.66% of the total distribution.
Only one is a senior nurse (3.33%). Based on Benner’s model, majority
are competent, while very few belong to the proficient and expert
categories.
In Polymedic General Hospital, nurses wear colored uniforms
(tan, yellow, blue) while only the trainees wear the traditional white
uniform without cap. Hair should be kept tidy but not necessarily in
a bun. Tying hair is very common. Earrings may be worn but should
not be dangling. In Maria Reyna Hospital, station nurses are to wear
white uniforms. In special areas such as ER, NICU, ICU, green or blue
scrub suits are worn and no cap. For the females, hair must be fixed in
a bun; males should sport a clean haircut. Wearing of jewelry is strictly
prohibited by the management. JR Borja Hospital strongly mandates
their nurses to wear white uniform; only DR Nurses are allowed to
wear scrub suits. Hair should be in a bun among the females and
must wear a cap. Male nurses should have clean, neatly trimmed hair.
Jewelry should not be worn while inside the hospital. All hospitals
mandate the wearing of white shoes.
When respondents were asked about their personal views of the
white uniform as standard attire in hospitals, 22 reacted positively
while 5 maintained a non-affirmative position on this. Three elicited
conditional responses to the query. The positive perceptions of the
respondents stem from the meaning of the color white. Based on
the claims of respondents, representations associated with wearing
a white uniform include neatness or cleanliness (1st), Identity and
Compliance to standard/appropriate (2nd), Good and Respect (3rd),
symbol of profession (4th), while good grooming, Professionalism,
good-heartedness, dignity, decency and fits profession (5th). Wearing
a uniform appears to contribute to the image being projected by
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an organization or profession and generally acknowledged by the
public. As suggested by Craik (2005), uniforms serve both social and
psychological impact to the one wearing it and society in general.
The conclusion of Joseph (1986) states, “The uniform serves several
functions: it acts as a totem, reveals and conceals status, certifies
legitimacy and suppresses individuality”. According to Major et al.
(2005), the color white is chosen for it symbolizes purity. Historically,
white uniforms facilitate patient identification and portrayed a clean
and neat image. Image and belongingness are yearned for the intrinsic
value to both the nurse and the institution and extrinsic significance
to the public. Literature showed that uniforms worn by nurses enable
patients and staff to readily recognize their role. When care is provided
by nurses, patients are inclined to believe they look more professional
and competent in white uniform with cap (Newton & Chaney, 1996).
Nurses’ appearance affects interactions with family members and may
shape patient family perceptions of nurse’s profession and image.
Additionally, non-standardization of uniform color in a single unit
or throughout the hospital may increase difficulty in differentiating
nurses from other hospital personnel (Albert et al., 2008).
The narratives pertaining to the significance of white uniform in
the nursing profession specifically centered on virtues/attributes
of effective nurses- cleanliness/purity (1st), respect (2nd), identity,
professionalism, passion for work and profession (3rd), smartness,
trademark of profession, beauty (4th), elegance, patience, nobility,
pride, honor, honesty, self discipline (5th). Albert et al. (2008) revealed
that white nursing uniforms consistently scored very highly in ten traits
which include empathy, cooperativeness, reliability, professionalism,
caring, efficiency, attentiveness, competence, and confidence. In the
health communication model of Northhouse and Northhouse (1998),
nurses’ uniform plays an important role in promoting a healthy nurseto-patient relationship. In like manner, image projected by wearing
white uniforms makes the public trust nurses. This comes from the
legitimacy that the nurse’s uniform symbolizes from the eyes of the
general public. Craik (2005) postulated, “Uniforms are extremely
effective indicators of the codification of appropriate rules of conduct
and their internalization”. What is more important is the set of rules
governing the institution of caring instead of the uniform itself. The
nurse’s white uniform enables the performance of legitimate activities
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closely tied to the occupation. In healthcare, this legitimacy enables the
nurse to approach and assess patients. The white uniform signifies that
the expertise and knowledge were formally earned through education
and training. If nurses behave in a manner which is not in tune with
society’s expectations, this may cause reduction in patient trust and
confidence (Castledine, 2004).
CONCLUSIONS
White uniforms play a vital role in protecting the image of nurses.
These views were constructed from culturally- and socially-based
definitions and images of nurses which led patients to hold them at a
highly-esteemed position for their professionalism and compassion.
Based on the findings, majority still are in favor of wearing white
uniform.
RECOMMENDATIONS
Based on the findings of the study, the following recommendations
are derived:
1.That Student nurses should be reminded during orientations
about the standard uniform for nurses to uphold it during their
entire life and that there may be modification according to the
policy of the institution.
2.That further research should be done on patients’ perceptions
with nurses wearing white uniform and according to nurses’ age
bracket and gender.
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